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CERTIFICATE. OF LIABILITY INSURANCE
<br />DATE (MMiQDf'YYYYI
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must, be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s),
<br />PRODUCER
<br />Earl Bacon Agency, Inc.
<br />P.O, Box 12039
<br />Tallahassee FL 32317
<br />CONTACT
<br />NAME: _. l�. a..fa.c..y_..L�,,.I.ta.-ch.e�.L o ......
<br />PHONE PAX 1.2 No.
<br />E Arc No .
<br />E -MAID
<br />INSURER S' AFFORDING COVERAGE
<br />NAIC #
<br />Y
<br />INSURER.Ar.: _I'aWortatlon Ins Company
<br />5095130327
<br />/112014
<br />INSURED M:GTOF -1
<br />..._.__
<br />INSURER B :Am ri. n .C:Q,.Qf .F..d.it,, PA
<br />$1,000,000
<br />MGT of America, Inc.
<br />Public Resource Management Inc.
<br />3800 Esplanade Way,Ste 210
<br />Tallahassee FL 32311 ry ((??
<br />2 G16 � a ,Sq
<br />INSURER C : _Q Ltt(I1IaLCsualty Company
<br />120443
<br />INSURER D:VQIley Forge Insurance Co.
<br />INSURER E :Tr v I rC 1 s. r m . fA l:
<br />a1194
<br />INSURER
<br />-
<br />$300,000
<br />COVERAGES CERTIFICATE NUMBER: 808488960 REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />_
<br />INSR
<br />LTR
<br />TYPE OF INSURANCE
<br />ADDL
<br />INSR.
<br />UBR
<br />WVD
<br />�. -.
<br />POLICY NUMBER
<br />lMM1D6IYYYY
<br />MM DDIYYYY
<br />LIMITS
<br />A
<br />GENERAL LIABILITY
<br />Y
<br />Y
<br />5095130327
<br />/112014
<br />1112015
<br />EACH OCCURRENCE
<br />$1,000,000
<br />x
<br />CLAIMS -MADE FX � OCCUR
<br />EAMAGE T EO
<br />PiEMISES La occurrence
<br />-
<br />$300,000
<br />MED EXP {Any one person)
<br />$5,000
<br />PERSONAL &ADV INJURY
<br />$1,000,000
<br />X A -XV Rating
<br />._.._._....._....... ._ _._.
<br />GENERAL AGGREGATE
<br />$2 „000.000
<br />PRODUCTS - COMPIOP AGG
<br />.
<br />$2,000,000
<br />GEN'L AGGREGATE LIMIT APPLIES PER:
<br />$ _..�
<br />X PRO-
<br />POLICY LOC
<br />B
<br />AUTOMOBILE
<br />LIABILITY
<br />Y
<br />Y
<br />2093563501
<br />1112014
<br />/112015
<br />COMB ED SIN(iLF LIMIT
<br />_ jEa accudent'I
<br />1,000,000
<br />ANY AUTO
<br />BODILY INJURY (Per person)
<br />$
<br />ALL OWNED SCHEDULED
<br />AUTOS AUTOS
<br />BODILY INJURY (Per accident)
<br />$
<br />X
<br />NON - OWNED
<br />HIRED AUTOS X AUTOS
<br />PROPERTY DAMAGE
<br />..,(Per accident
<br />.
<br />$
<br />$
<br />X..__
<br />A -XV Rating
<br />C
<br />x
<br />UMBRELLA LIAR
<br />x
<br />OCCUR
<br />2093563496
<br />1112014
<br />/112015
<br />EACH OCCURRENCE
<br />$$5,000,000
<br />AGGREGATE
<br />$$5,000,000
<br />EXCESS LIAR
<br />CLAIMS -MADE
<br />DED x RETENTION$ 10,000
<br />.
<br />�$
<br />D
<br />A
<br />WORKERS COMPENSATION
<br />ANQEMPLOYERS' LIABJLITY YIN
<br />Y
<br />3011086712 -AII Other
<br />3011086788 CA
<br />/112014
<br />/112014
<br />1112015
<br />11 /2015
<br />x TWO STATU- OTH-
<br />I I..
<br />CA EL -below
<br />E.L. EACH ACCIDENT
<br />$500,000
<br />ANY PROPRIETORIPARTNERIExECUTIVE D
<br />OFFICEWMEMBER EXCLUDED?
<br />NIA
<br />'... E.L. DISEASE • EA EMPLOYE
<br />$500,000
<br />(Mandatory in NHS
<br />If yS describe under
<br />DESCRIPTION OF OPERATIONS below
<br />E.L. DISEASE - POLICY LIMIT
<br />1 $500.,.000
<br />Professional Liabitity(E &O)
<br />Claims -Made Form
<br />105638880
<br />106080925-Cyber Liab.
<br />1112014
<br />/112014
<br />71112015
<br />/112015
<br />Per Claim 2,000,000
<br />Aggregate 3,000,000
<br />7/5195 Retro Date; A -XIV
<br />Cyber Liab. 1,000,000
<br />DESCRIPTION'.. OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
<br />!Umbrella: A -XV Rating. All Other Workers” Comp and CA Workers' Comp: A -XV Rating. California Employers Liability Limits: $1,000,000
<br />Each Accident/$1,000,000 Disease Policy Limit/$1,000,000 Disease Each Employee.
<br />CERTIFICATE HOLDER CANCELLATION
<br />City of Santa Ana
<br />20 Civic Center Plaza (M -30)
<br />P.O. Box 1988
<br />Santa Ana CA 92702 -1988
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE, THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS,
<br />AUTHORIZED REPRESENTATIVE
<br />@ 1988-2010 ACORD CORPORATION. All rights reserved
<br />ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORDl „y(I'(
<br />(� I/2
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